成人急性闌尾炎經非手術治療之臨床特質及預後分析

Abstract

在過去一百多年來，緊急闌尾切除術已成為治療急性闌尾炎的治療準則，然而，近年來已有不少研究論文顯示：急性闌尾炎亦可以經由非手術療法得到不錯的療效，然而因大多數的研究均屬於回溯性研究，鮮少前瞻性追蹤；再者，研究對象多集中在兒童，鮮少關於成人，因此本論文針對成人罹患急性闌尾炎、經由非手術療法之臨床特質及預後進行研究分析，收案時間自2003年1月至2009年12月，收案地點在臺大醫院，共有132位急性闌尾炎病患接受非手術療法治療。 本論文共分為四個子研究： 研究一：急性闌尾炎病患，決定接受緊急闌尾切除術或非手術療法，其臨床因子之對照研究 背景 針對急性闌尾炎病患，研究有無臨床因子決定病患接受緊急闌尾切除術或非手術療法。 方法 本研究採用病例對照研究，依據病患年紀(±5歲內)、性別及到院時間(±3個月內)進行配對，每個個案會有兩個對照組(接受手術者)，並以條件式羅吉斯迴歸模式進行統計分析。 結果 共有131位病患及262位對照組，經由多變項分析下，顯示疼痛時間較長勝算比, 1.48; 95%信賴區間, 1.20-1.81)、穿孔性闌尾炎(勝算比, 5.08; 95%信賴區間, 2.47-10.45)及血球分析中出現不成熟之白血球(勝算比, 6.01; 95%信賴區間, 1.00-35.97)的急性闌尾炎病患較常接受非手術療法。 結論 某些臨床因素的確可以決定急性闌尾炎病患接受手術或非手術治療。 研究二 急性闌尾炎病患，接受非手術療法成功治療後，其影響復發之危險因素 背景 針對急性闌尾炎病患，接受非手術療法成功治療後，其影響復發之危險因素之研究。 方法 收案對象為成功以非手術療法治療急性闌尾炎之病患，經由追蹤是否復發，而利用Kaplan-Meier法估算累積復發率，由Cox迴歸模式找出可能影響復發之危險因素。 結果 共有128位病患成功以非手術療法治療急性闌尾炎，追蹤期間平均為12個月(範圍, 1-90 個月)，期間共有20位病患發生復發，而21位病患接受延遲闌尾切除術。復發率約20%，而統計結果發現男性比女性更容易發生復發(勝算比, 3.45; 95%信賴區間, 1.15-10.39)，而穿孔性或非穿孔性闌尾炎之復發率並無差異，上述結果若將接受延遲闌尾切除術之患者排除後依然顯著。 結論 急性闌尾炎病患，接受非手術療法成功治療後，其復發率約20%，而男性較女性病患較容易復發。 研究三 急性闌尾炎病患，影響非手術療法失敗之危險因素 背景 針對急性闌尾炎病患，影響非手術療法失敗之危險因素之研究，以希望在決定治療前能先找出易失敗之病患。 方法 若病患接受非手術療法治療急性闌尾炎，然當次住院中轉為手術療法即視為失敗，其臨床變項與接受非手術療法成功治療者相比較。 結果 共有4位病患接受非手術療法治療失敗，統計結果顯示疼痛時間較短(p=0.002)、嗜中性球比例增加(p=0.027)及穿孔性闌尾炎合併膿瘍者(p=0.004)較容易失敗。 結論 急性闌尾炎病患若是合併膿瘍及疼痛時間較短，其接受非手術療法較易失敗。 研究四 急性闌尾炎病患接受非手術療法後，其超音波下發炎緩解之情形 背景 針對急性闌尾炎病患接受非手術療法後，其超音波下緩解情形之研究，希冀除了臨床症狀評估外，利用影像工具超音波來追蹤闌尾之變化。 方法 病患接受非手術療法治療急性闌尾炎後，接受3天一次超音波追蹤檢查，直到超音波下發炎狀況完全緩解。利用線性迴規模式分析達到緩解所需之時間與其他臨床因子是否有其相關性。 結果 共有80位病患完成三天一次之超音波檢查，共474人次，90%病患在30天內超音波影像上即緩解，而糞石之存在與緩解時間延長有正相關性(相關係數, 14.41; 95%信賴區間, 5.76-23.06)。 結論 該研究證實超音波在追縱病患接受非手術療法之應用性，而糞石之存在與緩解時間延長有正相關性。

Background: Recent evidence suggests appendectomy may not the only one management for acute appendicitis. However, previous studies were limited with retrospective design and pediatric population. This prospective study investigates the clinical characteristics and prognostic analysis of adult patients with acute appendicitis following nonoperative management (NOM) and consists of four component studies. Between January 2003 and December 2009, 132 adult patients were enrolled. PART 1: Matched analysis of NOM v.s. immediate appendectomy Aim: to investigate differences between the clinical parameters of patients treated nonoperatively and those treated with immediate appendectomy to clarify how the selection was made. Methods: By using case-control study, the 2 controls were individually matched to cases on gender, age (5 year-based groups) and recruited within 3 months of their matched case being identified. Conditional logistic regression models were applied. Results: There were 131 cases and 262 controls. Longer duration of pain (OR, 1.48; 95%CI, 1.20-1.81), perforated appendicitis (PA) (OR, 5.08; 95%CI, 2.47-10.45) and presence of bandemia (OR, 6.01; 95%CI, 1.00-35.97) were associated with patients receiving NOM. Conclusions: Selection bias existed in those patients receiving NOM, even though matched by age, gender and time of recruitment. PART 2: Risk factor for recurrent appendicitis following successful NOM Aim: to investigate recurrence rates and identifies predictive factors for recurrence. Methods: Adult patients who received NOM successfully were enrolled. Cumulative recurrence rates were calculated using the Kaplan-Meier method. Cox regression models were employed to identify parameters that significantly predict recurrence. Results: 128 patients were enrolled. The median follow-up period was 12 months (range, 1-90 months). Twenty patients developed recurrence and another 21 patients underwent interval appendectomy (IA). Roughly 20% of the adult patients experienced recurrence. No significant difference existed between non-perforated (NPA) and PA groups for recurrence rates. Moreover, male gender was significantly associated with recurrence (3.45; 95% CI, 1.15-10.39). Analytical results remained significant after excluding IA patients. Conclusions: Roughly 20% of the adult patients experienced recurrence. Males were more susceptible than females to recurrent appendicitis. PART 3: Risk factor for failure in the NOM of acute appendicitis Aim: to investigate the predictive factor for failure in the NOM. Methods: Patients were treated surgically during the same hospital stay and considered as treatment failure. The characteristics of these patients were compared with those with success. Results: Four patients (3%) had treatment failure with shorter duration of pain (p=0.002), more percentage of neutrophils (p=0.027) and abscesses (p=0.004). Conclusions: 3% patients did not respond for NOM. Abscesses with shorter duration of pain predicted failure. PART 4: Sonographic resolution following NOM Aim: to investigate the status of appendix following NOM via ultrasound. Methods: The patients received repeat sonographic examinations with 3-day interval until resolution, and the time to achieve resolution was recorded. Linear regression models were used to identify the relationship between the time to achieve sonographic resolution and clinical parameters. Results: 474 sonographic examinations were performed. Seventy-two (90%) patients achieved sonographic resolution less than 30 days. An appendicolith was positively related to the time to achieve resolution (coefficient: 14.41, 95%C.I, 5.76-23.06). Conclusions: This study demonstrates the feasibility of using ultrasound to determine success following NOM. The presence of an appendicolith would delay sonographic resolution of appendicitis